Low-Value Care in Washington

Low-value care is one of the current buzzwords for health care.  The Choosing Wisely initiative attempted to identify certain low-value services that physicians should avoid ordering.  So now everyone is focused on this.  The state of Washington attempted to identify how much low-value care is delivered there.   (Wash. Report)   The report is based on Choosing Wisely, and used 47 services or procedures which are often described as inappropriate or unnecessary.  Concerns about unnecessary services include the cost, but also the potential for physical injury to a patient during the course of treatment and the mental stress that results from concerns about health and receiving any health care service.  In looking at the use of the services in a segment of the state’s population, the authors decided that 45% of the time these services were low-value.  They used a tool developed by Milliman, called the “Health Waste Calculator” that uses algorithms to identify duplicative and likely inappropriate services.  Milliman is an excellent firm, but they have a tendency to grossly overestimate unnecessary care and any attempt to categorize services without patient examination obviously has a subjectivity to it.

For the 2.4 million people in the commercial claims database in the test group, there were a total of 1.5 million services which were in the 47 categories of potentially wasteful ones.  46% were found by the algorithms to be low-value, another 1.35 were likely low value and 52% were necessary.  48% of the population were said to have received at least one low-value service and those services represented 36% of all services, resulting in $282 million in wasted spending.  Eleven specific services accounted for 93% of the wasted care and 89% of the associated spending.  Those include cervical screening, lab tests prior to surgery, eye disease imaging, uncomplicated headache imaging, low back pain imaging, PSA screening, antibiotics for upper respiratory and ear infections and annual EKGs.  The authors go on to issue a call to action to reduce use of these services in the state.  A few of my usual observations on the topic.  Note how many of these services relate to defensive medicine.  Note the tension between some algorithm and some remote expert deciding what is unnecessary and the judgment of the physician actually looking at and treating the patient.  And of course, there has to be as much concern to ensure that patients get all the necessary care they are currently missing.  If you got every patient the exact right care they needed all the time, I think our health spending would go up, not down.